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12030007 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10779 JUNIPER Cf CONTRACTOR:ELIZABETH TING PERh11T NO: 12030007 OWNER'S NAME: ELIZABETH TING 10779 JUNIPER Cr DATE ISSUED:03/022012 OWNER'S PHONE: 6509671500 CUPERTINO.CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMNIERCIAL IJ License Class Lie.# INSTALL CAS LINE FOR FUTURE FIREPIT AND BBQ Contractor Date hereby affirm that 1 am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. 1 hereby affirm under penalty of perjury one of the following two declarations: I have and mill maintain a certificate of conscnt to self-insure for Worker's Compensation,as provided for by Section 3700 of die Labor Code,for the performance of the work for whichthis permit is issued. Sq.Ft Floor Area: Valuation:$2779 I have and will maintain Worker's Compensation.Insurance,as provided for by Section 3700 of(lie Labor Code,for die performance of the work for which this APN Number:34257011.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I cenify chat I have read this application mid state dim the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.I agree m comply with-all city and county ordinances and state Imus relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments. / / costs,and expenses whidm may accrue against said City in consequence of dies/�� /,!n—r�� .�,� •�J grating of this permit. Additionally,the applies t understands mid will comply Issued by: ..✓✓✓ ///��/�-/i Date: with alb nam-point source regulations per the Cupertino Municipal Code,Sectio 9.18. RE-ROOFS: Signature Date All roofs shall be inspected prior to any rooting material belie installed.If a roof is installed withoa first obtaining an inspection.I agree to remove all new materials for inspection. OWNER-BUILDER DECLARATION 1 hereby affirm That 1 am exempt front the Connector's License Law for one of Signature of Applicant: Date: time following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I,as owner of the property,or my employees with wages as their sole comp:nsatiom. will do time work,aid the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) 1,as owner of the property.am exclusively commetng with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Cr+de). I have read the hazardous materials requirements wader Chapter 6.95 of the California Health&Safety Code.Sections 25505.25533.and 25534. [mill 1 hereby affirm under penalty of perjury one of the following three maintain mm pliance what the Cupertinn Municipal Code.Cha pier 9.12 and the declarations[ Health&Safety Code,Section 25532(a)should 1 store or handle hazardous 1 have and will maintain aCenificate of Consent to setf-insure for Worker's material. Additionally,should 1 use equipment at,devices which each hazardous Compensation,as provided for by Section 3700 of the Labor Code.for time air contaminants os defined be the Bay Area Air Quality Management District 1 performance of[he work for whichthis penin is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by time Health&Safely Code,Sections 2,U05.25533.anjl 25534. Section 3 700 of the Labor Code.for die performance of the work for which this Permit is issued. Ownerar authorized mgenCte: 3 2-- I I artily dial in the performance of the work for which this permit is issued,I shall not employ any Person in my mamur so as tobecome subject In the Worker's Commpensatiom Imus of Cal ifrmia. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCV become sul+ject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of tiorthwilh comply with such provisions or this permit shall be deemed revoked w'ork's for which this permit is issued(Sec.3097.Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address I certify that 1 have read this application and state that the above information is correct.1 agree to comply with all cit•and county ordinances and state laws relating to building construction,mid hereby authorize representatives of this city to enter upon the above mentioned property fix inspection purposes.(We)agree in save ;ARCHITECT;S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may acerae against said City in consequence of die I understand ray plans shall be used as public records. graining of dhis permit.Additionally,[he applicant understands and will comply with all non-point source regulations per the Cupenino Municipal Code,Section Licensed Professional 9.18. Signature Date Z CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION VA ADDRESS: 10779 Juniper Ct DATE: 03/02/2012 REVIEWED BY: Sean APN: BP#: `VALUATION: 1$2,779 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition /Repair PRIMARY SFD or Duplex PENTAMATION 1 RPGAS USE: PERMIT TYPE: WORK Install clas line for future fire it and BBQ. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Piping, Gas <=4 Outlets 1PGASRES 1 # $65 TOTALS: $65.00 Lbs n ",:•t:n.,k Plutnb.Plat Check 0.0 hrs $0.00 Flee.Plan C'hecA "m h Plumb. Permit Fee: IPPERAIIT Eh, I'.ru., 1., v.,,, u. o lrni Other Plumb Insp. 0.0 hrs $44.00 Ul1u+ Elec. bop 1,—t, 1r-,p l"', Plumb. Imp.Fee: ElCe Iny. Fee NOTE: This estinwte does not include jeer due to other Depanmems(i.e. Planning,Public Works, Fire,Sanitary Seiner District School District,etc.). These ees are based on the prelininarj in orntal/on available and are only an estinwie. Contact the Depi for addn'I info. FEE ITEMS (Fee Resolution 11-053 EH 711111) FEE QTY/FEE MISC ITEMS Phtn C'hd4 Fet. sup/'l PC l-i'r PME Plan Check: $0.00 A7.1nit he c S111)10 )'111, Fe" PME Unit Fee: $65.00 PME Permit Fee: $44.00 ('otctrac•nun lot. Administrative Fee: IdDARN $41.00 Work Without Permit? 0 Yes (j) No $0.00 dt".1,.ed/'/annul",Fees: Travel Documentation Fee: ITRA PDOC $44.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC 1 $1.00 SUBTOTALS: 1 $195.501 $0.001 TOTAL FEE: $195.50 Revised: 1/19/2012 CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 34257011.00 DATE ISSUED. . . . . . . : 03/02/2012 RECEIPT #. . . . . . . . . : SS000016167 REFERENCE ID # . . . : 12030007 SITE ADDRESS . . . . . : 10779 JUNIPER CT SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : ELIZABETH TING ADDRESS . . . . . . . . . . : 10779 JUNIPER CT CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : ELIZABETH TING CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY . . . . . . . . . . : ELIZABETH TING ADDRESS . . . . . . . . . . : 10779 JUNIPER CT CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 TELEPHONE . . . . . . . . : FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- -ADMIN HOURS 1 .00 41.00 0. 00 41 .00 0 . 00 1BCBSC VALUATION 2, 779 .00 1.00 0.00 1 .00 0 .00 1BPGAS OULETS 1 .00 65.00 0.00 65 .00 0 .00 1BSEISMICR VALUATION 2,779 .00 0 .50 0.00 0 .50 0 .00 1PPERMITFE FLAT RATE 1 .00 44 .00 0.00 44 .00 0 .00 1TRAVDOC FLAT RATE 1 . 00 44 . 00 0 .00 44 .00 0 .00 ---------- ---------- ---------- ---------- TOTAL PERMIT 195 . 50 0 .00 195 .50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- -------------- -------------------- CREDIT ------------------ CREDIT CARD 195 .50 ax --------------- TOTAL RECEIPT 195 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 506 GAS TEST 507 FINAL PLUMBING 2 OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO,CA 95014-3255 C V PERTINO (408)777-3228• FAX(408)777-3333• buildino5cuoertino.orc Dear Property Owner(s): An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at: SITE ADDRESS 117-1,7 / JUr7I ^,, / APN BP# OWNER NAME 0]1.24 ('n l/ -OWNER ADDRESS /0-7y Jon; -f/I C� DESCRIPTION OF WORK: `fit( d-er f^L We are providing you with an Owner-Builder Acknowledgment and Information Verification Form to make you aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner-Builder. We will not issue a building permit until you have read, initialed your understanding of each provision, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you;the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.) 1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner- Buil ler" building permit that erroneously implies that the property owner is providing his or her own labor and material personally. 1, as an Owner-Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. —42. 1 understand building permits are not required to be signed by property owners unless they are responsible for the construction and are not hiring a licensed Contractor to assume this responsibility. 0 3. 1 understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. _U4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license nu hers on permits and contracts. V5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value of my construction is at least five hundred dollars($500), including labor and materials, I may be considered an"employer" under state and federal law. _Q_6. 1 understand if I am considered an "employer' under state and federal law, I must register with the state and federal government, withhold payroll taxes, provide workers'compensation disability insurance, and contribute to unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial risk. 7. 1 understand under California Contractors' State License Law, an Owner-Builder who builds single-family residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. _48.'I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for any financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction defects in the workmanship or materials. OwnerBuilderForm ?010.doe revised 04/14/10 J A9. 1 understand I may obtain more information regarding my obligations as an"employer"from the Internal Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752)or www.cslb.ca.gov for more information about licensed contractors. l 10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am (he party legally and financially responsible for proposed construction activity at the site address listed above. V 11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner-Builders as well as employers. V112 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does not have a license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be held liable for damages. If you obtain a permit as Owner-Builder and wish to hire Contractors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS:Please complete the following construction lending agency information.) I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec 3097 Civ.) Lender Name: Lender Address: Before a building permit can be issued, this form must be completed and signed by the property owner and returned to the agency responsible for issuing the permit. Note:A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's si nat e. Property Owner's Signature: J Date: /L --------------------------------------------------------------------------- - ----------------- - --------------------------------------------- (NOTE: The following Authorization Form is required to be completed bythe property owner only when designating an agent of the property owner to apply for a construction permit for the Owner-Builder). AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the following person(s)to act as my agent(s)to apply for, sign, and file the documents necessary to obtain an Owner-Builder Permit for my project. Scope of Construction Project(or Description of Work): Project Location or Address: Name of Authorized Agent: Tel No Address of Authorized Agent: I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Note:A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: OwnerBuilderForm 1010.doc revised 04114/10 GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 w w ' CUPERTINO (408)777-3228 • FAX(408)777-3333• buildina(cDcuoeri'ino.ora /` I\r,� v` PLUMBING ❑MECHAMCAL ❑II.ECIRICAL A 2 U3�U� 2 ❑MISCELLLYEOUS PROJECT ADDRESS AFN I 3y 2 5-7 6 ' I II OWNERNANE C I ZA I_V e4+\ /n 'HONE W- q&,7—Kb J E c n/"' CTM cCsk STREET ADDRESS li l I OILY SLATE,M- FAX /1 p i CONTACT NAME I PHONE E-MAA STREET ADDRESS CITY.STATE ZIP FAX OWNER ❑ owNER-BIJL'DR ❑ OWNER AGENT ❑ CONTRACTOR ❑CON, (7OR AGEvr ❑ ARO=Cr ❑ENGIN ❑ DEVMZpM ❑ IIIUNT CONS'tA� 1/~ Ium Gi llCENSENJN ER j LICENSE TYPE BUS.LIC0 2ige-I-2 COIKIANY MA , E-MAIL FAX r'vner�� STREET ADDRESS r, ARCRTECT/ENOINEER NAME LICENSE N1NBE2 BUS.uC 0 CONfPA.NY NAME' E-MAIL FAX STREET ADDRESS I =,STATE,ffi - PHONE USE OFSFO or OfJPI�I (/MUTLFAIWLY PROF NWR-DLWD ❑ YTS 2ROtECT P1 ❑ YES ISTfLEBIDGAN 1:1 YES .L=" ❑COM1LMcR Y' URBAN MTFAFACE AREA NO I FLOOD ZONE NO Elclu HHONER 10-NO DFSCAI]MON OF WORK TOTAL VALUATJON: D O RECEIVED BY: By my signabr_below,I c=,. w each ofl:he following I am tc p<oPery awac er anc5o =d agent w att on to prop'ry�owvr/=''ss behalf I have read this apoGcatan and the mformadoo I have provided is cer:ecL`}have red the Descptan aI Work and verify it is ancLTaL- [agrx to cormly with all applicable local ord¢Iances and sate laws relatag to buil ' g_consy//ecI5on�I au'uorize cepr-3ea[anves o:Cupertino to enter the above-ideeed/5edgpn/p�ery;arinsper5on purposes. Signature o,`ApplicandAgenD C7- Dare: LI fill/7i SUPPLE'Y N 1 AL(`IFOR,LATION REQUIRED -,IOF ICE USE ONLY v (3 OVER-THE-COUNTER ❑ EXPRESS Y U y ❑ sTA.NDARD U S ❑ LARGE L ❑ M Olt MEPMac4pp20l Ldoc revised 06/11/11